management of hyperemesis gravidarum guidelines - copy
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DR. MEENAKSHI SHARMA DR. SHARDA JAIN DR. JYOTI BHASKAR DR. JYOTI AGARWAL
MANAGEMENT OF
HYPEREMESIS GRAVIDARUM LATEST GUIDELINES UPDATE
2015
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MANAGEMENT OF
HYPEREMESIS GRAVIDARUM LATEST GUIDELINES UPDATE
MANAGEMENT OF
HYPEREMESIS GRAVIDARUM -
GUIDELINES
Dr Meenakshi Sharma
Dr. Sharda Jain
Dr. Jyoti Bhaskar
Dr. Jyoti Agarwal NICE 2013
ACOG 2010
SOGC 2002
HYPEREMESIS GRAVIDARUM
Severe nausea & intractable vomiting
Affects - 0.3-2% of pregnancies
PATHOPHYSIOLOGY Pathophysiology – multifactorial
HCG– increased levels in pts with HG as HCG stimulates secretions in upper GIT
Estrogen- positive assoc b/w NVP and maternal serum E2 level. Increased E2 causes a decrease in GI motility and gastric emptying altering GI pH and encourages subclinical H pylori infection
Thyroid hormone- physiological gestational transient thyrotoxicosis. Raised FT3 & low TSH found in 66% HG
Symptoms
NauseaVomitingEnhanced olfactory sensesFood and/or fluid intoleranceLethargy
HYPEREMESIS GRAVIDARUM
HYPEREMESIS GRAVIDARUM
Signs
DehydrationWeight lossKetonuriaAnaemiaTachycardia
HYPEREMESIS GRAVIDARUM
HYPEREMESIS GRAVIDARUM
Initial InvestigationsUrea and ElectrolytesLFTCBCUrinalysisUSG-multiple/molar pregnancies
Additional investigationsCalciumBlood sugarTSH
HYPEREMESIS GRAVIDARUM
HYPEREMESIS GRAVIDARUM
COMPLICATIONS Maternal
Hypokalemia Hyponatremia and central pontine myelinosis Wernickie’s encephalopathy Vitamin B6/B12 deficiency Malnutrition Mallory- Weiss esophageal tears Venous thromboembolism Psychological morbidity
Fetal Growth restriction Wernicke’s encephalopathy is associated with
40% fetal death
COMPLICATIONS
Hyponatremia (Na<120 mmol/l) - anorexia, headache, nausea, vomiting and lethargy
Severe hyponatremia may lead to central pontine myelinolysis (osmotic demyeliniation) Pyramidal tract signs Spastic quadriparesis Pseudobulbar palsy Altered sensorium Ataxia and convulsion
It is medical emergency Should be managed
appropriately by skilled personnel
As treatment may be potentially as dangerous as the condition itself
Vitamin B1 deficiency precipitated by IV fluid containing high concentration of dextrose Ophthalmoplegia (typically sixth nerve palsy,
diploia), Ataxia Altered sensorium
Diagnosis confirmed by low red cell transketolase, a thiamine dependent enzyme
MRI - symmetrical lesion around the aqueduct and fourth ventricle, which resolve after treatment with thiamine
TREATMENT
Thiamine replacement may improve the symptoms of Wernicke’s encephalopathy
if associated with Korsakoff psychosis (retrograde amnesia, impaired ability to learn and confabulation) the recovery rate is only about 50%
40% incidence of fetal death
Differential Diagnosis System
Diagnosis
Genitourinary UTI Uraemia Molar pregnancy
Gastrointestinal Gastritis/ peptic ulcer Reflux/ oesophagitis Pancreatitis Bowel obstruction
Endocrine Addison’s disease Hyperthyroidism Diabetes ketoacidosis
CNS Intracranial tumours Vestibular disease
Correction of dehydration and electrolyte imbalance
Prophylaxis against recognized complications
Provision of symptomatic relief
Admit if :Symptom are severe despite 24 hrs of
medicationEvidence of dehydration and ketosisAdmit earlier if coexisting conditions eg
diabetes
IV fluid- NS and Hartmann’s solution preferrable if ketotic or fluid intolerant
Avoid dextrose solution as can’t correct commonly associated
hyponatraemia High conc of dextrose solution
precipitate Wernicke’s encephalopathy
Avoid double strength saline even in cases of severe hyponatraemia
Antiemetics are safe and recommended liberally in HG
Pts on antiemetic -better pregnancy outcome due to better nutrition
REMEMBER !!!!! MEDICATION TO BE KEPT TO MINIMUM
Class of drugs Antiemetic
Phenothiazine Prochlorperazine (stemetil/ buccastem) Chlorpromazine
Dopamine antagonists Metoclopramide Domperidone
5-HT3 (serotonin) antagonist Ondansetron
Antihistamines (H1 receptor antagonist)
Cyclizine Promethazine (phenergan) Meclozine
Group One Dose Route
First line Cyclizine 50 mg t.d.s. PO, IM or IV
Second line Prochlorperazine (Stemetil)
12.5 mg t.d.s. 3-6 mg b.d
IM sublingual
Third line Metoclopramide 10 mg t.d.s. PO, IM or IV
Group two:
Promethazine (phenergan)
25 mg a day IM/oral
Chlorpromazine 10-25 mg t.d.s. 25 mg t.d.s.
PO
Domperidone 20 mg qds 30-60 mg qds
PO PR
Steroids should be used for intractable hyperemesis which is not responding to above management
I/V Hydrocortisone 100 mg BD for 48 hrs
Oral prednisolone 30 – 40 mg/day -1 week then tapered gradually 5mg reduction every week
Increased risk of VTE due to dehydration and immobilization in hospitalized pts.
LMWH should be given if the risk factor score for VTE is 3 or more
Pre-existing risk factors Score
Previous recurrent VTE 3
Previous unprovoked or estrogen related
3
Previous VTE provoked 2
Family history of VTE 1
Known thrombophilia 2
Medical comorbidity 2
Age (> 35 years) 1
Obesity 1 or 2 *
Parity (≥ 3) 1
Smoker 1
Gross varicose vein 1
Obstetric risk factors 1
Pre-eclampsia 1
Dehydration/ Hyperemesis/ OHSS
1
Multiple pregnancy or ART 1
Transient risk factors
Current systemic infection 1
Immobility 1
Surgical procedure in pregnancy
2
Total score
Risk assessment for Venous
Thromboembolism (VTE)
*Score 1 for BMI >30 *Score 2 for BMI >40
Prolonged nausea & vomiting Intolerable to fluid and/or food Clinical dehydration Ketouria Weight loss
Nausea & vomiting History of other medical condition e.g diabetes,
Summary for Management of Hyperemesis Gravidarum-NHS 2013
Admission
Admission
Initial assessment Temp, Pulse, Resp, BP, Body weight U&E LFT Urinalysis/ MSU USS
Additional investigations FBC (full blood count) Blood glucose TFT (thyroid function test) Calcium
Diagnosis
Treatment
Subsequent assessment Fluid intake output chart
U&E (urea and electrolytes), LFT (liver function test
Alternate day if initial results were normal, daily if the results
were abnormal
Fluid & electrolyte replacement Normal saline/
Hartmann’s 3 litres/day
KCl (potassium/ about 100 mmol/24
hr)
All hyperemesis Pabrinex 250 mg thiamine per pair
weekly if oral thiamine is not
tolerated. Clexane (as per
protocol)
Antiemetics (1st group) 1st line: Cyclizine 50 mg t.d.s. PO, IM or IV2nd line: Prochlorperazine 12.5mg t.d.s. IM Buccastem 3-6mg bd sublingually
Third line: Metoclopramide 10 mg t.d.s. PO IM or IV
Intractable vomiting
Antiemetics (2nd group)
Promethazine (phenergan) 25 mg a
day IM/oral Chlorpromazine 10-25
mg t.d.s. PO 25 mg t.d.s. IM
Domperidone 10 mg q.d.s PO
30-60 mg b.d PR
With consultant decision
Ondansetron 4-8 mg b.d. PO, IM or IV
Hydrocortisone 100 mg b.d. IV for 48 hr followed
by: Prednisolone 30-40 mg
o.d. PO for one week then reduce the dose by 5
mg/week
Other supportive treatment
• Diet & lifestyle (small frequent dry meal, learn to avoid certain scents which make the patient intolerable)
• Ginger • Acupressure/
acupuncture
The options for severe hyperemesis who failed to response to above measures
• Enteral nutrition• Parenteral nutrition
(TPN)• Termination of
pregnancy
A doxylamine/pyridoxine combination should be the standard of care, since it has the greatest evidence to support its efficacy and safety. (I-A)
H1 receptor antagonists should be considered in the management of acute or breakthrough episodes of NVP. (I-A)
Pyridoxine monotherapy supplementation may be considered as an adjuvant measure. (I-A)
Phenothiazines are safe and effective for severe NVP. (I-A)
SOGC 2002, ACOG 2010
HYPEREMESIS GUIDELINES Metoclopramide is safe to be used for
management of NVP, although evidence for efficacy is more limited. (II-2D)
Corticosteroids should be avoided during the first trimester because of possible increased risk of oral clefting and should be restricted to refractory cases. (I-B)
When NVP is refractory to initial pharmacotherapy, investigation of other potential causes should be undertaken. (III-A)
SOGC 2002, ACOG 2010
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